COPD Care at Sligo University Hospital: Progress, Impact and Future Plans in a Nursing Context

Introduction: Chronic obstructive pulmonary disease (COPD) is a progressive lung disease characterised by persistent airflow obstruction that is partially reversible. Clinically, it manifests as worsening dyspnoea and, in advanced stages, frequent exacerbations requiring medical intervention in primary care, emergency settings, or hospital admissions. COPD represents a major public health challenge in Ireland, significantly contributing to respiratory mortality. Despite global improvements, Ireland continues to report one of the highest age-standardised mortality rates for COPD among European nations.

The prevalence of COPD in Ireland is estimated at approximately 380,000 people. Despite this, only about 110,000 individuals have been formally diagnosed, leaving a significant proportion undiagnosed and untreated. It is a leading cause of morbidity and mortality in Ireland, with at least 1,500 deaths annually and over 15,000 hospital admissions attributed to the condition.

Sligo University Hospital (SUH) is part of the HSE West North West region, and is a public model three acute hospital with a catchment area extending to Sligo, Leitrim, South Donegal, West Cavan, as well as parts of Mayo and Roscommon. The hospital has 288 inpatient beds and provides 24/7 Emergency Medicine care, as well as various Medical and Surgical specialities.

Inpatient Services – History and Development

Over the years, the hospital’s respiratory service has expanded from a team of one Respiratory Physician, one Clinical Nurse Specialist (CNS), and one Respiratory Physiologist to a multidisciplinary team including three Respiratory Physicians, two acute CNS, one CNS in Non-Invasive Ventilation, one CNS in COPD Outreach and one Advanced Nurse Practitioner (ANP) 50:50 Hospital and Integrated Care. There is also a Respiratory Integrated Care Team in the community comprising of two Respiratory CNS, and two Clinical Specialist Physiotherapists, two Respiratory Physiologists and a Pulmonary Rehabilitation Team.

The inpatient Respiratory CNS service plays an integral role in the care of patients with COPD. Key areas of focus include inpatient reviews, education, management of non-invasive ventilation (NIV), long term oxygen ordering and referrals to Respiratory Physiology and Pulmonary Rehabilitation. One of the most recent significant developments was the CNS team’s integration into the Emergency Department (ED) which allows the team to identify COPD patients earlier in their hospital stay, enabling timely interventions and better care coordination ensuring these patients are transferred to the Respiratory ward.

Inpatient Reviews

The respiratory CNS inpatient review service is a key component of COPD care, offering guidance to multidisciplinary teams across various specialties. Patients are typically referred with an established diagnosis of COPD, but those who present with symptoms suggestive of COPD are also assessed then referred to the Respiratory ANP for further investigations if appropriate. The team also optimise inhaler regimens, ensuring appropriate medications, while providing education on correct inhaler techniques to improve adherence. More complex patients are discussed with the respiratory physician on consults. Through this comprehensive approach, the CNS service ensures COPD patients receive tailored, evidence-based care during their hospital stay.

Education

Education is a cornerstone of effective COPD management, empowering patients to take control of their condition and improve their quality of life. A primary focus is on inhaler technique and the importance of medication adherence, as incorrect use of inhalers or inconsistent medication routines can significantly worsen symptoms and lead to exacerbations. Patients are also educated on the importance of winter vaccines in reducing exacerbations and maintaining lung function. Smoking cessation remains a critical area of education, as it is the most effective intervention for slowing disease progression. Additionally, patients benefit from learning to recognise the early signs of exacerbations, enabling them to seek timely intervention and avoid hospital admissions.

Non Invasive Ventilation

The CNS team plays a pivotal role in initiating and managing non-invasive ventilation (NIV) for patients with acute respiratory failure due to COPD exacerbations. We assess the patient’s clinical condition and recommend appropriate ventilator settings, including pressures and FiO2 levels, to optimise oxygenation and carbon dioxide clearance. Once NIV is initiated ongoing support and troubleshooting is provided to address challenges such as mask fit, pressure leaks, or discomfort. These patients are transferred to the Respiratory Unit for ongoing specialist care. Ensuring effective use of NIV and addressing complications promptly significantly improves patient outcomes.

Long Term Oxygen Therapy

Managing patients on home oxygen therapy is another vital aspect of our role, ensuring optimal care and safety for those requiring long-term oxygen support. We work closely with our respiratory consultants to titrate oxygen, tailoring therapy to meet the patient’s needs while preventing complications such as hypercapnia. Our responsibilities also include providing phone support to patients, addressing concerns, monitoring their progress, and coordinating care. Additionally, we are often called to assess patients to determine their eligibility for home oxygen. For those who are not candidates, we evaluate alternative management plans to ensure that oxygen therapy is used effectively to enhance patient outcomes and quality of life.

COPD Outreach Service

The COPD Outreach service at Sligo University Hospital was established in May 2023 to address the growing burden of COPD on acute healthcare services. COPD exacerbations are a leading cause of hospital admissions and bed occupancy, yet they are recognised as an ambulatory care sensitive condition—meaning timely and appropriate community-based care can significantly reduce hospitalisations. With funding from the Enhanced Community Care (ECC) programme, the service was launched as a proactive, multidisciplinary initiative designed to improve patient outcomes, reduce healthcare utilisation and empower individuals to manage their condition more effectively.

History and Development

The team consists of one Respiratory CNS and one Clinical Specialist Physiotherapist with governance from the Respiratory Consultant. National COPD Outreach guidelines provided the foundation for the programme, which were customised to meet the unique needs the catchment area.

a targeted approach, where respiratory consultants handpicked patients for inclusion. By June 2023, it expanded to include all medical patients admitted with an acute exacerbation of COPD who met the inclusion criteria. This criteria focused on patients with confirmed COPD who could engage with a self-management program and lived within a 35km radius of the hospital. Exclusion criteria included conditions such as pneumonia, pneumothorax, or social circumstances that made home care unfeasible.

Service Implementation

The COPD Outreach service has two major streams.

1. Supported Discharge

Patients admitted with an acute exacerbation are followed up post-discharge for two weeks during this time they remain under the care of the respiratory consultant. They typically receive two to three home visits, depending on their clinical needs. Each visit includes:

• Monitoring of vital signs and symptoms.
• Clinical assessments, including chest auscultation and symptom questionnaires.
• Education on inhaler technique, early exacerbation recognition, and medication adherence.
• Discussions about goals of care and referrals to pulmonary rehabilitation or other services.

Patients who avoid admission during the two-week follow-up are reviewed again at six weeks, with a discharge summary sent to their GP.

2. Admission Avoidance

Admission avoidance targets patients who had previously engaged with COPD Outreach. Patients experiencing exacerbations at home contact the team directly for an initial phone triage. If deemed appropriate, a same or next day home visit is arranged. Nurse prescribed treatments are initiated during these visits, including oral steroids and antibiotics, often avoiding the need for hospital admission. These interventions are supported with advice from the respiratory consultant.

Both arms of the service emphasise patient empowerment, equipping individuals with the knowledge and tools to manage their disease proactively. In July 2024 we undertook an audit to measure the impact of the COPD outreach service on hospital admissions and bed days. There were 68 accepted patients enrolled in the programme between May 2023 and March 2024, see table 1 for patient demographics of the audit carried out on 38 patients meeting

pre-defined inclusion criteria.

Results and Evaluation

During this time the COPD Outreach service demonstrated significant benefits with hospital admissions: Reduced by 78%, from 1.68 to 0.37 admissions per patient and hospital bed days reduced by 70%, from 10.39 to 3.08 bed days per patient. See Figure 1.

The COPD Outreach service has demonstrated the significant impact of a tailored, community-based approach to managing COPD. By reducing hospital admissions and bed days through proactive supported discharge and admission avoidance pathways, the programme has not only improved patient outcomes but also alleviated the strain on hospital resources.

ANP service

The introduction of a Respiratory ANP post in 2022 led to a focus on capturing people who attended the hospital with chronic respiratory conditions but were not known to respiratory services. Currently one of the aims of the service is to reduce COPD exacerbations and ED/ hospital visits, through early diagnosis, assessment and management. This development is aligned with the Integrated Model of Care for the Prevention and Management of Chronic Disease, ensuring timely diagnosis, streamlined patient pathways, and comprehensive follow-up care.

Service implementation

The ANP-led service identifies and manages patients via two pathways

1. Emergency Department (ED) Pathway:

Patients presenting to the ED with respiratory conditions, including suspected or exacerbated COPD, are reviewed by the Respiratory CNS or ANP, a full assessment is carried out and treatment is optimised based on symptoms. If appropriate these patients are followed-up in the Respiratory ANP clinic in the Benbulbin Chronic Disease Management (CDM) Hub for further assessment, investigations and management.

For patients who present Out of Hours a referral form is sent to the Respiratory ANP who contacts the patient to triage review and arrange follow-up in the Benbulbin CDM Hub. Patients are typically reviewed within 1–4 weeks of their initial presentation, gaining access to diagnostics, tailored management plans, and self-management education.

2. Inpatient Pathway:

Patients admitted to non-respiratory specialties with COPD symptoms are flagged for review. The respiratory CNS optimises treatment during their admission, with follow-up review by the ANP in the Benbulbin CDM hub this ensures ongoing follow-up care in the community. See figure 2 for ANP referral pathway.

The ANP-led clinic operates twice weekly at the Benbulbin Chronic Disease Management (CDM) Hub, offering an efficient, “one-stop shop” approach to patient care. The patient undergoes pulmonary function testing followed by a consultation with the ANP. A comprehensive health assessment is conducted. The clinic offers ABG analysis, referral for chest x-ray, bloods and sputum monitoring. Education on COPD management is provided, ensuring patients are informed about their condition. Treatment plans are reviewed and optimised in line with national and international COPD guidelines to ensure best practices. See Figure 3 for an overview of the clinical pathway. Most patients are discharged back to their GP with follow-up in the Chronic Disease Management Programme in primary care. This integrated approach supports early intervention, enhances patient education, and facilitates continuity of care.

Service outcomes

Between January 2023 and June 2024, 268 patients were reviewed in the ANP clinic.

COPD specific outcomes

• 93 patients with COPD were seen, of which 81 were new referrals.
• 72% of new referrals had same-day PFTs.
• 37 new diagnoses of COPD were made see figure 4
• 20 patients were referred to pulmonary rehabilitation.
• 52 patients were discharged from the ANP clinic, while 7 were referred to a respiratory consultant.

The ANP-led COPD service is closely aligned with the HSE COPD Model of Care and the Respiratory National Clinical Programme. By bridging emergency, inpatient, and community services, this model ensures that patients receive diagnostic services, treatment plans, and access to multidisciplinary teams—all within a streamlined, patient-centred framework. This seamless integration of acute and community care improves health outcomes and supports the sustainability of respiratory services at Sligo University Hospital.

Future plans

There are many exciting projects happening in terms of COPD care but nationally and internationally. We would like to focus on the use of remote patient monitoring for real-time assessment of COPD exacerbations and expansion of tele-monitoring to detect exacerbations early and reduce hospital admissions.

We are concentrating more on treatable traits and identifying characteristics and phenotypes which respond to specific targeted treatments which means we can provide personalised precision medicine. We see the improvement in quality of life biologics have made to people with asthma and there has been exciting research on expanding the role of biologics for people who have severe COPD with asthma overlap.

We also know that COPD rarely exists in isolation. We are beginning to appreciate that many diseases co-exist with COPD and they also interact. This is obviously the case for cardiovascular disease. There is a potential to hold joint Respiratory and Cardiology clinics in the CDM hub to better manage symptoms such as breathlessness.

COPD care by the Respiratory Nursing Team at Sligo University Hospital exemplifies a patient-centred, multidisciplinary approach, integrating acute and community services. From innovative inpatient reviews to the establishment of COPD Outreach and the ANP-led clinic, these services have demonstrated significant improvements in patient outcomes, resource utilisation, and quality of life.

Written by Lorna Nellany, Respiratory Advanced Nurse Practitioner, Nathan Scanlon, COPD Outreach Clinical Nurse Specialist, Sligo University Hospital

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